- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.65 / $1,962.90 / $1,962.90
| Professional | | $1,085.65 | $1,962.90 | $1,962.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.28 / $1,697.91 / $1,946.41
| Professional | | $1,091.28 | $1,697.91 | $1,946.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,702.02 / $1,805.18 / $2,494.90
| Professional | | $1,702.02 | $1,805.18 | $2,494.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $176.51 / $1,830.62
| Professional | | $32.34 | $176.51 | $1,830.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.96 / $2,208.44 / $2,494.90
| Professional | | $2,052.96 | $2,208.44 | $2,494.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.83 / $1,307.02 / $2,149.05
| Professional | | $1,146.83 | $1,307.02 | $2,149.05 |